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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. J•' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County .Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address - �_1/2 C) 11/ 414, 7 �[ __ - -- - --- City U.O <br /> San oaquinu�o.. �` <br /> Contractor's Name (Division of Son Joaquin Suiphur Caj J License � 10 Phone <br /> ill N. acrameo o St. <br /> Lodi, Caliturnlu =iv <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Ocher <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER i <br /> PROPERTY'L-INE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �•` <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ 13 <br /> Cathodic,P_rotection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: /a;r/ State Work DoneAalwee_ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthewell in use.. The above <br /> information is true to the best of my knowledge an - belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN AL INSP TIO N' San Joaquin.Pump C®, <br /> SIGNED r/ TITLE (Division of <br /> (DRAT LOT PLAN ON REVERSE SIDE) 711 N. ar <br /> f. FOR DEPARTMENT USE ONLY, 10di, Califernia 95240 <br /> PHASE T i <br /> APPLICATION ACCEPTED BY;;� _ DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION,'_ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE' INSPECTION 'S DATE Z9_ <br /> ' n,�7 7 2M <br />